Pennsylvania Department of Health
WESLEY ENHANCED LIVING - DOYLESTOWN
Building Inspection Results

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WESLEY ENHANCED LIVING - DOYLESTOWN
Inspection Results For:

There are  39 surveys for this facility. Please select a date to view the survey results.

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WESLEY ENHANCED LIVING - DOYLESTOWN - Inspection Results Scope of Citation
Number of Residents Affected
By Deficient Practice
Initial comments:Name: - Component: -- - Tag: 0000


Based on an Emergency Preparedness Survey completed on April 1, 2024, at Wesley Enhanced Living - Doylestown, it was determined there were no deficiencies identified with the requirements of 42 CFR 483.73.




 Plan of Correction:


Initial comments:Name: MAIN BUILDING 01 - Component: 01 - Tag: 0000


Facility ID# 085502
Component 01
Main Building

Based on a Medicare/Medicaid Recertification Survey completed on April 1, 2024, it was determined that Wesley Enhanced Living - Doylestown was not in compliance with the following requirements of the Life Safety Code for an existing Nursing health care occupancy. Compliance with the National Fire Protection Association's Life Safety Code is required by 42 CFR 483.90(a).

This is a nine-story, Type II (222) fire resistive building, that is fully sprinklered on the first floor health care portion of the building.




 Plan of Correction:


NFPA 101 STANDARD HVAC:This is a less serious (but not lowest level) deficiency and affects more than a limited number of residents, staff, or occurrences. This deficiency is one that results in minimal discomfort to the resident or has the potential (not yet realized) to negatively affect the resident's ability to achieve his/her highest functional status. This deficiency was not found to be throughout this facility.
HVAC
Heating, ventilation, and air conditioning shall comply with 9.2 and shall be installed in accordance with the manufacturer's specifications.
18.5.2.1, 19.5.2.1, 9.2




Observations:
Name: MAIN BUILDING 01 - Component: 01 - Tag: 0521

Based on document review and interview, it was determined the facility failed to maintain Heating, Ventilating and Air Conditioning (HVAC) equipment, affecting three of nine levels.

Findings include:

Document review on April 1, 2024, at 9:00 a.m., revealed the May 15, 2023, fire damper inspection report listed the following deficiency: (8) Fire Dampers did not function properly on 5/15/23 and need to be replaced. Documentation of subsequent repairs was not available at time of survey.

Exit Interview with the Administrator and Maintenance Director on April 1, 2024, at 11:35 a.m., confirmed the missing documentation.





 Plan of Correction - To be completed: 05/31/2024

Director of Facility Operations is to have fire dampers repaired by contracted vendor and necessary documentation procured stating that the dampers are repaired, tested, and are functioning properly.

Inspection schedule to be placed into TELS maintenance program and reported on during quarterly Quality Assurance meetings with the Executive Director/Nursing Home Administrator and the Director of Nursing.

NFPA 101 STANDARD Electrical Systems - Other:This is a less serious (but not lowest level) deficiency and affects more than a limited number of residents, staff, or occurrences. This deficiency is one that results in minimal discomfort to the resident or has the potential (not yet realized) to negatively affect the resident's ability to achieve his/her highest functional status. This deficiency was not found to be throughout this facility.
Electrical Systems - Other
List in the REMARKS section any NFPA 99 Chapter 6 Electrical Systems requirements that are not addressed by the provided K-Tags, but are deficient. This information, along with the applicable Life Safety Code or NFPA standard citation, should be included on Form CMS-2567.
Chapter 6 (NFPA 99)
Observations:
Name: MAIN BUILDING 01 - Component: 01 - Tag: 0911

Based on observation and interview, it was determined facility failed to maintain protection of electrical wiring, affecting one of nine levels.

Findings include:

Observation on April 1, 2024, at 11:00 a.m., revealed, on the first floor, in the kitchen, an electrical panel was blocked by various items.

Exit Interview with the Administrator and Maintenance Director on April 1, 2024, at 11:35 a.m., confirmed the obstructed electrical panel.

~Refer to the 2011 edition of NFPA 70, 110.26 (A) (1)





 Plan of Correction - To be completed: 05/31/2024

Maintenance staff to install slip resistant black and yellow tape on floor around electrical panels giving a 3-foot clearance. Signage to be placed on wall stating that there cannot be storage within the perimeter of marked floor.

Kitchen staff are to be in-serviced on electrical panels and the proper clearance around. Kitchen managers to procure documentation and sign off sheet of the in-service.

To be monitored on semi-annual safety surveillance rounds and reported to Wesley Enhanced Living's Safety Committee and reported by Director of Facility Operations to the quarterly Quality Assurance committee with the Executive Director/ Nursing Home Administrator and the Director of Nursing.

NFPA 101 STANDARD Electrical Systems - Essential Electric Syste:This is a less serious (but not lowest level) deficiency and affects more than a limited number of residents, staff, or occurrences. This deficiency is one that results in minimal discomfort to the resident or has the potential (not yet realized) to negatively affect the resident's ability to achieve his/her highest functional status. This deficiency was not found to be throughout this facility.
Electrical Systems - Essential Electric System Maintenance and Testing
The generator or other alternate power source and associated equipment is capable of supplying service within 10 seconds. If the 10-second criterion is not met during the monthly test, a process shall be provided to annually confirm this capability for the life safety and critical branches. Maintenance and testing of the generator and transfer switches are performed in accordance with NFPA 110.
Generator sets are inspected weekly, exercised under load 30 minutes 12 times a year in 20-40 day intervals, and exercised once every 36 months for 4 continuous hours. Scheduled test under load conditions include a complete simulated cold start and automatic or manual transfer of all EES loads, and are conducted by competent personnel. Maintenance and testing of stored energy power sources (Type 3 EES) are in accordance with NFPA 111. Main and feeder circuit breakers are inspected annually, and a program for periodically exercising the components is established according to manufacturer requirements. Written records of maintenance and testing are maintained and readily available. EES electrical panels and circuits are marked, readily identifiable, and separate from normal power circuits. Minimizing the possibility of damage of the emergency power source is a design consideration for new installations.
6.4.4, 6.5.4, 6.6.4 (NFPA 99), NFPA 110, NFPA 111, 700.10 (NFPA 70)
Observations:
Name: MAIN BUILDING 01 - Component: 01 - Tag: 0918

Based on document review and interview, it was determined the facility failed to maintain required testing of emergency generator components, affecting one generator.

Findings Include:

Document review on March 25, 2024, at 9:00 a.m., revealed the facility lacked verifying documentation of the following emergency generator maintenance items:

a. monthly testing of battery electrolyte specific gravity or conductance testing.

Exit Interview with the Administrator and Maintenance Director on April 1, 2024, at 11:35 a.m., confirmed the missing documentation.




 Plan of Correction - To be completed: 05/31/2024

Facility to purchase a Hydrometer to measure the battery's electrolyte specific gravity monthly.

Findings are to be documented on the monthly generator inspection checklist that is part of the TELS maintenance program.

Director of Facility Operations is to monitor the monthly inspection checklists and report at monthly Wesley Enhanced Living's safety committee meeting and to the quarterly Quality Assurance committee with the Executive Director/Nursing Home Administrator and the Director of Nursing.

NFPA 101 STANDARD Electrical Equipment - Power Cords and Extens:This is a less serious (but not lowest level) deficiency and affects more than a limited number of residents, staff, or occurrences. This deficiency is one that results in minimal discomfort to the resident or has the potential (not yet realized) to negatively affect the resident's ability to achieve his/her highest functional status. This deficiency was not found to be throughout this facility.
Electrical Equipment - Power Cords and Extension Cords
Power strips in a patient care vicinity are only used for components of movable patient-care-related electrical equipment (PCREE) assembles that have been assembled by qualified personnel and meet the conditions of 10.2.3.6. Power strips in the patient care vicinity may not be used for non-PCREE (e.g., personal electronics), except in long-term care resident rooms that do not use PCREE. Power strips for PCREE meet UL 1363A or UL 60601-1. Power strips for non-PCREE in the patient care rooms (outside of vicinity) meet UL 1363. In non-patient care rooms, power strips meet other UL standards. All power strips are used with general precautions. Extension cords are not used as a substitute for fixed wiring of a structure. Extension cords used temporarily are removed immediately upon completion of the purpose for which it was installed and meets the conditions of 10.2.4.
10.2.3.6 (NFPA 99), 10.2.4 (NFPA 99), 400-8 (NFPA 70), 590.3(D) (NFPA 70), TIA 12-5
Observations:
Name: MAIN BUILDING 01 - Component: 01 - Tag: 0920

Based on observation and interview, it was determined the facility failed to prohibit the unauthorized use of electrical devices affecting one of nine levels.

Findings include:

Observation on April 1, 2024, at 11:15 a.m., revealed, on the first floor, in the administrative area, a microwave was plugged into a surge protector.

Exit Interview with the Administrator and Maintenance Director on April 1, 2024, at 11:35 a.m., confirmed the unauthorized electrical device.




 Plan of Correction - To be completed: 05/31/2024

The microwave and power strip were removed from the administrative area immediately.

The Director of Facility Operations is to conduct an in-service for the administrative staff on the proper use of surge suppressors and electrical appliances in a Health Care setting. Documentation and a sign off sheet are to be procured.

To be monitored on semi-annual safety surveillance rounds and reported to Wesley Enhanced Living's safety committee and to the quarterly Quality Assurance committee with the Executive Director/Nursing Home Administrator and the Director of Nursing.

NFPA 101 STANDARD Gas Equipment - Cylinder and Container Storag:This is a less serious (but not lowest level) deficiency and affects more than a limited number of residents, staff, or occurrences. This deficiency is one that results in minimal discomfort to the resident or has the potential (not yet realized) to negatively affect the resident's ability to achieve his/her highest functional status. This deficiency was not found to be throughout this facility.
Gas Equipment - Cylinder and Container Storage
Greater than or equal to 3,000 cubic feet
Storage locations are designed, constructed, and ventilated in accordance with 5.1.3.3.2 and 5.1.3.3.3.
>300 but <3,000 cubic feet
Storage locations are outdoors in an enclosure or within an enclosed interior space of non- or limited- combustible construction, with door (or gates outdoors) that can be secured. Oxidizing gases are not stored with flammables, and are separated from combustibles by 20 feet (5 feet if sprinklered) or enclosed in a cabinet of noncombustible construction having a minimum 1/2 hr. fire protection rating.
Less than or equal to 300 cubic feet
In a single smoke compartment, individual cylinders available for immediate use in patient care areas with an aggregate volume of less than or equal to 300 cubic feet are not required to be stored in an enclosure. Cylinders must be handled with precautions as specified in 11.6.2.
A precautionary sign readable from 5 feet is on each door or gate of a cylinder storage room, where the sign includes the wording as a minimum "CAUTION: OXIDIZING GAS(ES) STORED WITHIN NO SMOKING."
Storage is planned so cylinders are used in order of which they are received from the supplier. Empty cylinders are segregated from full cylinders. When facility employs cylinders with integral pressure gauge, a threshold pressure considered empty is established. Empty cylinders are marked to avoid confusion. Cylinders stored in the open are protected from weather.
11.3.1, 11.3.2, 11.3.3, 11.3.4, 11.6.5 (NFPA 99)
Observations:
Name: MAIN BUILDING 01 - Component: 01 - Tag: 0923

Based on observation and interview, it was determined the facility failed to maintain storage of oxygen cylinders, affecting one of nine levels.

Findings include:

Observation on April 1, 2024, at 10:20 a.m., revealed an unsecured oxygen cylinder, on the first floor, in the Director of Nursing' s Office.

Exit Interview with the Administrator and Maintenance Director on April 1, 2024, at 11:35 a.m., confirmed the unsecured oxygen cylinders.




 Plan of Correction - To be completed: 05/31/2024

The facility is to order appropriate storage racks and appropriate signage for resident rooms where oxygen is to be used.

The facility developed a written protocol for staff to follow when oxygen is delivered by a medical equipment vendor. The Director of Nursing is to conduct an in-service with all Nursing staff about this protocol and the Director of Nursing is to procure documentation and a sign off sheet.

To be monitored during semi-annual safety surveillance rounds and reported to Wesley Enhanced Living's safety committee and to be reported by the Director of Facility Operations during quarterly Quality Assurance meetings with the Executive Director/Nursing Home Administrator and the Director of Nursing.


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